AIRWAY ADJUNCT

DISAMPAIKAN OLEH; GOODMAN BIN MOSITI

PENOLONG PEGAWAI PERUBATAN U29 (BIUS)

DEWAN BEDAH, HOSPITAL PITAS

KURSUS “BASIC LIFE SUPPORT”

(BLS)

PENGENALAN

• Sebahagian peralatan tambahan / bantuan yang digunakan bagi pengendalian dan pengurusan salur pernafasan mangsa.

• Membantu membuka saluran pernafasan pesakit / mangsa semasa tidak sedarkan diri dan memudahkan dalam pemberian oksigen (ventilasi) kepada.

Mekanisma Semasa Pesakit Tidak Sedar Diri

• Pesakit tidak dapat menjaga salur pernafasan sendiri.

• Salur pernafasan akan tersumbat oleh; -Lidah (Flacid tongue) -’Relaxed hypopharyngeal’ -Epligotis -Muntah -Gigi palsu -Dsb

ALGORITHM AIRWAY OPENINGUnresponsive

PatientUnresponsive

Patient

Manual Maneuver

Manual Maneuver

DefinitiveAirway

DefinitiveAirway

ABC(AIRWAY OPENING /

CARE)

ABC(AIRWAY OPENING /

CARE)

Airway AdjunctAirway Adjunct

•Oropharyngeal•Nasophryngeal•LMA•Proceal•Intubating LMA•Combitube

•Oropharyngeal•Nasophryngeal•LMA•Proceal•Intubating LMA•Combitube

•Surgical Airway•Surgical Airway•Head Tilt

Chin Lift•Jaw Trust•Modifed Jaw Trust

•Head Tilt Chin Lift•Jaw Trust•Modifed Jaw Trust

•Endotracheal Tube (ETT)•Endotracheal Tube (ETT)

-Oral-Nasal-Oral-Nasal

-Jet Insufflation-Cricothyroidotomy-Tracheostomy

-Jet Insufflation-Cricothyroidotomy-Tracheostomy

JENIS-JENIS OROL AIRWAY

OROPHARYNGEAL AIRWAY

• Oral Airway / OPA / Guedel Airway• Dicipta oleh Arthur E. Guedel (1883-1956)• Size: 000,00,0,1,2,3,4,5,6 / Colour Code• Kebaikan:- Mudah didapati / dikendali - Memudahkan “Suction” -Bite Block (mengelak pesakit menggigit tiub ETT ) -Kurang Allergen

OROPHARYNGEAL AIRWAY• INDIKASI;

-Pesakit yang tidak sedar diri

-Pesakit spontaneusly breathing

-Total hilang gag reflex

-Digunakan sebagai bite block

• KONTRAINDIKASI;

-Pesakit sedar, ada gag reflex, susah buka mulut, masive oral trauma

-Mandibulo-maxillary wiring

• KOMPLIKASI;

-Terlalu panjang: Menekan epligotis

-Terlalu pendek : Menolak lidah ke belakang

-Menyebabkan batuk, muntah dan laryngospasme

-Aspiration

OROPHARYNGEAL AIRWAY

• Menentukan Size OPA: i) Coner of mouth to earlobe ii) Against patient’s face to angle of the mandible

OROPHARYNGEAL AIRWAY

• Tatacara memasukkan OPA-Bersihkan oral pesakit (suctioning)Teknik 1) Guna tongue blade untuk menekan lidah pesakit dan

masukan OPA ke belakang (disarankan untuk infant). 

Teknik 2) Insert the oral airway upside down until the soft palate is reached.  Rotate the device 180 degrees and slip it over the tongue.

step 1 step 2 step 3 step 4

NASOPHARYNGEAL AIRWAY• Dikenali juga sebagai NPA / nasal trumpet• Diperbuat daripada getah / plastik lembut • Mula diperkenalkan pada 1972.• INDIKASI;-Pesakit spontaneously breathing-Pesakit yang dikontraindikasi bagi Guedel airway-Boleh digunakan walaupun pesakit ada gag reflex-Pesakit tidak di intubasi.

• KONTRAINDIKASI;-Kakitangan tidak terlatih-Kecederaan kepala / muka yang teruk-Basal Skull fracture-Hidung tersumbat / jangkitan-Struktur Kongenital, bleeding disorder

NASOPHARYNGEAL AIRWAY

• Size;-12F, 14F, 16F, 18F 34F, 36F-Guna ukuran Internal diammeter (I.D) -Pilihan size; ? sama besar dengan jari

klingking pesakit-Penjang (mm); Tip of nose to tragus

of the ear

NASOPHARYNGEAL AIRWAY

• Tatacara;-Pilih saiz yang sesuai-Sapukan NPA dengan Lignocaine jel-Pilih lubang hidung yang tidak tersumbat-Masukkan dengan berhati-hati (elak kecederaan)-Jika terdapat resistant, pusing sedikit NPA-Kekalkan Head tilt

NASOPHARYNGEAL AIRWAY

• KOMPLIKASI;-Terlalu Panjang:- Kecederaan pada

epligotis / vocal cord / vagal stimulation

-Injured nasal mucosa; pendarahan-Alahan-Kurang Selesa

LARYNGEAL MASK AIRWAY• Supraglottic airway management device. • Also called LMA• Designed between 1981 and 1988 by Dr. Archie I. J.

Brain.• Cuff device that provides sufficient seal to allow for

positive pressure ventilation to be delivered• Tiga komponen utama: airway tube, mask, and inflation

line• Alternative airway device used for anesthesia and

airway support in emergency (difficult intubation). • It is inserted blindly into the pharynx, forming a low-

pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation.

• All parts are latex-free.

LARYNGEAL MASK AIRWAY

• Indications:-The Laryngeal Mask Airway is an appropriate

airway choice when mask ventilation can be used but endotracheal intubation is not necessary.-Guide for endotracheal intubation (Fastrach)-Unanticipated difficult intubations -Failed intubation -Intubation of patients with limited head/neck movement

LARYNGEAL MASK AIRWAYType of LMA Description LMA Classic (CLMA)

LMA (ambu)

he original LMA airway with the basic features and components

Designed base an oral structure

LMA Unique A disposable version of the CLMA

LMA ProSeal (PLMA) An advanced form of LMA that has been specifically designed for use with positive pressure ventilation (PPV) with and without muscle relaxants at higher airway pressures

LMA Flexible

Single Use LMA Flexible

Both of these feature a wire-reinforced, flexible airway tube that allows it to be positioned away from the surgical field

LMA Fastrach An intubating LMA that is designed to facilitate intubation with a special flexible cuffed endotracheal tube (ETT)

LMA Ctrach A variant of the LMA Fastrach with an integrated fiberoptic system that allows visualization of the anatomical structures immediately in front of the aperture of the mask via a detachable, portable color display screen

LARYNGEAL MASK AIRWAY

Proceal LMA

LMA Classic LMA Fastrach

LMA Unique

ETT for LMA Fastrach

Handle of Proceal

LMA Classic

LMA Ambu

LARYNGEAL MASK AIRWAY

Proceal LMA Fastrach LMA

PANDUAN SAIZ LMA

LARYNGEAL MASK AIRWAY

Advantages Disadvantages

Increased speed and ease of placement by inexperienced personnel Lower seal pressure

Increased speed of placement by anesthetists Higher frequency of gastric insufflation

Improved hemodynamic stability at induction and during emergence

Minimal increase in intraocular pressure following insertion

Reduced anesthetic requirements for airway tolerance

Lower frequency of coughing during emergence

Improved oxygen saturation during emergence

Lower incidence of sore throats in adults

Contraindications to LMA Use Non-fasted including patients whose fasting cannot be confirmed

Grossly or morbidly obese

>14 weeks pregnant

Multiple or massive injury

Acute abdominal or thoracic injury

Any condition associated with delayed gastric emptying

Patients with a fixed decreased pulmonary compliance

Patients where the peak inspiratory pressures are anticipated to exceed 20-30 cm H2O

Adult patients who are unable to understand instructions or cannot adequately answer questions regarding their medical history

TATACARA MEMASUKKAN LMA

LANGKAH-LANGKAH MEMASUKAN LMA

1. Press the mask up against the hard palate. Note the flexed wrist.

2. Slide the mask inward, extending the index finger

3. Press the finger towards the other hand, which exerts counter-pressure

4. Advance the LMA cuff into the hypopharynx until resistance is felt

5. Hold the outer end of the airway tube while removing the index finger

Correct position of LMA

COMPLICATION USE LMA

• Oral trauma• Laryngo-spasm• Aspiration • Incorrect position; hypoxia• Dislodge

COBRA LMA

TERBARU….!!!!

COMBETUBE

• The Combitube is a twin lumen device designed for use in emergency situations and difficult airways. It can be inserted without the need for visualization into the oropharynx, and usually enters the esophagus. It has a low volume inflatable distal cuff and a much larger proximal cuff designed to occlude the oro- and nasopharynx

• If the tube has entered the trachea, ventilation is achieved through the distal lumen as with a standard ETT. More commonly the device enters the esophagus and ventilation is achieved through multiple proximal apertures situated above the distal cuff. In the latter case the proximal and distal cuffs have to be inflated to prevent air from escaping through the esophagus or back out of the oro- and nasopharynx.

COMBITUBE

COMBITUBE

• Used effectively in cardiopulmonary resuscitation and patient with difficult airways secondary to severe facial burns, trauma, upper airway bleeding and vomiting where there was an inability to visualize the vocal cords.

• It can be used in patients whose cervical spine has been immobilized with a rigid cervical collar.

• The Combitube can only be used in the adult population as no pediatric sizes are available.

• Complications of the Combitube include an increased incidence of sore throat, dysphagia and upper airway hematoma when compared to endotracheal intubation and LMA.

• Esophageal rupture is a rare complication but has been described.

ENDOTRACHEAL TUBE

• Called ETT / ET Tube• Used in GA, ICU, EM, • Invasive Airway management• Mechanical Ventilation• Sir Ivan Whiteside Magill (1888-1986)

TRACHEAL INTUBATION

• Oral• Nasal• Fiberoptic endoscopy

INDICATIONS

• Provide patent airway• Prevent aspiration• Facilitate IPPV• Operative positions• Difficult airway maintenance• Suction of respiratory tract• Thoracic operations• Disease involving upper airway

PERALATAN UNTUK INTUBASI• Laryngoscope and spare• ET tubes/ connector• Stilette• Magill forceps• 20 ml syringe• Securing tapes / bandage• LA 4 % lignocane spray• Cocaine gel - nasal• Lubricant• Throat packs• GA machine, face mask, airways

PREPARATION

• Assess patients• Oral versus nasal intubation?• Check equipment• Assistant required• Check Ventilator / BVM• check suction pump• Correct sizes of scopes and blades• Correct sizes of ET tubes

Equipment Required for Successful Intubation (F.E / M.A.L.E.S)

• TYPE OF INDUCTION 1.Rapid sequence induction2. Normal sequence induction

• OROTRACHEAL INTUBATION

1. Position of the patient-Height of table-Elevate patient’s head-Use of head ring/ pad under

occiput

Technique of Endotracheal Intubation

-Sniffing position-Align oral, pharyngeal and

laryngeal axis-Lips to glottic opening - straight

line-Open patient’s mouth with right

thumb

2.Direct laryngoscope-Hold laryngoscope in Lt hand-Insert blade into Rt side of mouth-Deflect the tongue to the left

3. VISUALIZE THE EPIGLOTTIS

-Advance blade in the midline-Until epiglottis visualized-Advance tip of blade into vallecula-Or beneath epiglottis - straight blade-Forward & upward movement-Elevate epiglottis-Expose glottic opening-Depression of thyroid cartilage-Exposure of glottic opening

4. PLACEMENT OF ET TUBE-Introduce tube with Rt hand-Through Rt side of mouth-Advance tube through glottic

opening-Until calf just passes vocal cord-Remove scope blade-Inflate the cuff-IPPV – absence of air leak

5.CONFIRMATION OF ET TUBE PLACEMENT

-Co2 in exhaled gases-Bilateral breath sounds-Epigastric auscultation-Fogging of water vapour in

tube-Maintenance of O2 saturation

6. Secure tube with tape/ bandage7.Continue IPPPV

• NASAL INTUBATION-Dental / ENT operations-Long term intubation-Pre- formed nasal tube-Smaller in size

-Choose nostril that breath more easily

-Lubricate tube-Insert tube through nostril-Advance tube until tip visualized in

the orophargynx-Advance distil end of ET tube into

tracheal through visualizes glottic opening

-Used of magill forceps-Avoid damage to cuff-Confirm tube placement-Cuff tube-Insertion of moist gauze pack-Secure tube

FIBREOPTIC INTUBATION

• Difficult airway/ intubation• Glottic opening cannot be

visualised• Awake intubation • Oral or nasal

• ORAL ET TUBE SITE GUIDELINE

AGE INTERNALDIAMETER(mm) LENGTH(cm)

Premature 2.5 10

neonate 3.0-3.5 10-11

6-12mth 11-123.5-4.0

2 years 4.5 13

4 years 5.0 14

6 years 5.5 15

8 years 6.0 16

10 years 6.5 17

12 years 7.0 18

• ORAL ET TUBE SIZE GUIDELINESAGE

ADULT

INTERNAL

DIAMETER

(mm)

LENGTH

( CM )

Female 7.0-7.5 18-20

Male 7.5-9.0 22-24

• FORMULA: For paediatric : • Internal diameter : 4+ age mm

length : 12 + age mm ( oral )

nasal : 15 + age mm

4

2

2

• COMPLICATIONS OF ENDOTRACHEAL INTUBATION

1.During intubation• Aspiration • Malpositioning• Esophageal intubation• Endobronchial intubation• Aspiration• Dental damage• Injury to lips and gums

• Activation of sympathetic nervous system• Bronchospasm• Sore throat• Dislocated mandible

2. AFTER EXTUBATION• Aspiration• Laryngospasm• Transient vocal cord incompetence• Glottic or subglottic oedema

• Pharyngitis or tracheitis

DIFFICULT INTUBATION• 1 in 65 patients• Difficulty with laryngoscopy• Cause of mobidity & mortality• sequelae- dental & airway trauma- pulmonary aspiration-hypoxaemia

• CAUSES OF DIFFICULT INTUBATION• Inadequate assessment• Inadequate equipment preparation• Inexperience• Poor technique

• Equipment-Malfunction-Unavailability-No trained assistant

• PATIENT• Congenital-syndromes ( Down’s, Pierre – Robin)• Achondroplasia• Cystic hygroma• Encephalocele

• Acquired-Reduced jaw movement i) Trismus ii) Fibrosis

- tumours- Jaw wiring

• Reduced neck movement- Rheumatoid / osteoarthritis- ankylosing spondylitis- cervical # / fusion• Airway- oedema- compression- scarring

- tumours/ polyps- Foreign body- Nerve palsy

• Others- mobid obesity- pregnancy- acromegaly

• ANATOMICAL FACTOR : DIFFICULT LARYNGOSCOPY

• Short neck• Protuding incisions• Long high arched palate• Receding lower jaw• Poor mobility of mandible anterior depth of mandible• Reduced jaw opening• Reduced neck extension

DIFFICULT INTUBATION KIT• Airway adjuncts • Gum elastic bougies/ ET tubes• Cricothyrotomy needle• Jet ventilation• Maccoy Blade

Extreme Clinical Situations

• Tracheostomy• LA

CLASSIFICATION OF MALLAMPATI TEST

Kong Thau Chin

FAIL INTUBATION PROTOCOL